Healthcare Provider Details

I. General information

NPI: 1023635430
Provider Name (Legal Business Name): JESSICA OBIDIMALOR NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165-17 145TH ROAD
JAMAICA NY
11434
US

IV. Provider business mailing address

165-17 145TH ROAD
JAMAICA NY
11434
US

V. Phone/Fax

Practice location:
  • Phone: 347-570-5153
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number309587
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: